[Pain management in surgical wards. Quality and solutions for improvement in the early postoperative period]. / Schmerzmanagement auf chirurgischen Bettenstationen. Qualität und Optimierbarkeit frühpostoperativer Schmerzbetreuung.

INTRODUCTION: Following guidelines pain levels should not exceed a score of 3 on the visual analog scale (VAS 1-10). We were interested in the actual surgical pain management of the postoperative period and the potential influences of a nurse-controlled intravenous morphine administration (NCA) on its quality. METHODS: Interventional study: interview of patients and nursing staff and examination of records concerning pain treatment following surgery. RESULTS: The interviews were conducted with 110 patients before and 125 patients after the intervention program. Before the intervention, one-half of the patients noted that they were never asked about their pain intensity within the first 24 h after surgery. Only 42% of the records showed at least one VAS documentation. Every fourth individual experienced a pain intensity > 3 without having received a supplementary pain medication. Following the morphine intervention program, documentation of pain scores increased significantly (72%; p < 0.0001) and more patients were familiar with the VAS (64% vs 46%; p < 0.0004). Median maximum as well as actual pain at the time of the interview decreased by one point (VAS). The percentage of patients whose supplementary pain prescription was totally used showed a significant increase (p = 0.035). Following morphine administration, no single individual complained about an undue waiting time in comparison to 15% of patients previously. Even though the morphine intervention project caused more work for the nursing staff, 75% of the personnel were convinced that the procedure was worth this investment. CONCLUSION: This data revealed a relevant deficiency of surgical pain management. Already basic instructions on pain management can significantly improve this treatment. Assigning additional authority to the nursing staff, such as a nurse-based intravenous opioid administration, can significantly raise the motivation of the personnel as well as the satisfaction of the patients involved.

[Optimizing postoperative pain therapy on acute surgical wards]. / Optimierung der postoperativen Schmerztherapie auf chirurgischen Akutstationen.

UNLABELLED: The aim of this interdisciplinary project was the improvement of postoperative pain management on surgery wards of an university hospital: Pain medication should be enlarged with the possibility to administer an opium-medication i.v. (non only s.c.) when needed (VAS > 3), which has been tested on two wards. The study shows the resulting changes of the intervention for patients and nurses. For recording, there has been patient questionnaires and document analysis before and after the new possibility to administer medication, and a nurses opinion survey. RESULTS: 110 resp. 125 patients and 39 nurses have been interviewed. Although there were only few patients (8%) during the second registration who did get the morphine i.v., there were clear tendencies: More patients have been asked about their pain-intensity and recognized the visual analog scale (VAS) (p = 0.0004) and less patients found, that they had to wait for a pain-medicament too long. There was a significant reduction of maximal pain-scores (p = 0.02) and also a significant improvement of nursing supplementary pain medication (p = 0.035). Actual pain-scores and use of basis-analgesia were slightly reduced resp. improved with the intervention. Overall patient-satisfaction regarding the treatment of their pain was high in both groups (> 95%). Nurses found (88%), that the new possibility to administer the morphine i.v. when needed, was good, even though this intervention and the controls of the vital signs requires more work. They said, that very often, it is worth the extra work, and for 31% of them, the focus on pain became more important through the intervention. CONCLUSIONS: The enlargement to administer pain medication and asking/registering pain intensity regularly, created more sensitivity for the patient's pain-experience among nurses, and this lead to better use of the prescribed pain medication and to better pain management overall. Further quality-improvement in post-operative pain relief seems possible by continuing on that way in the future.

Common nerve blocks in chronic pain management.

Anesthesiologists have become increasingly involved with the management of chronic pain patients in the operating room, on the surgical floor, and in the outpatient pain facility setting (often interdisciplinary). Based upon the authors' practice of regional anesthesia, the most specific contribution to chronic pain management arguably remains the practice of diagnostic, prognostic, and therapeutic injections of the neuraxis, peripheral nerves, and the autonomic nervous system.

Combined effect of patient variables on sensory level after spinal 0.5% plain bupivacaine.

BACKGROUND: The combined effect of age, weight, height, and vertebral column length (VCL) on the distribution of isobaric 0.5% bupivacaine within the subarachnoid space is unclear. The aim of the present study was to evaluate the combined influence of these patient variables on the upper sensory level and on its predictability. METHODS: In 100 patients who were above the age of 49 years, the age, weight, height, VCL, body surface (BS), and body mass index (BMI) were noted. Spinal puncture and subarachnoid drug administration were standardized. Cephalad spread of spinal anaesthesia (SA) was assessed by loss of temperature sensation and pinprick discrimination 15, 30, 60, 90, and 120 min following subarachnoid injection of 18 mg of plain 0.5% bupivacaine. Linear regression analysis was performed for each of the patient variables and the cephalad segmental spread of anaesthesia. Multiple regression analysis was used to test for combined correlation between patient variables and the sensory level of SA. RESULTS: No linear correlation was found between the patient variables and the sensory level of anaesthesia. In contrast, multiple regression analysis revealed that age (P<0.01), weight (P<0.05), and height (P<0.01) significantly contributed to the spread of anaesthesia. A squared multiple comparison coefficient between 0.10 and 0.21, however, is an indication that the predictive value of the combined variables remained rather low. CONCLUSION: Multiple regression analysis revealed that age, weight, and height significantly correlated with the sensory level after subarachnoid injection of plain bupivacaine. The low predictive value suggests that patient factors other than age, weight, or height add to cephalad spread of SA.

Reduction of covalent binding of aflatoxin B1 to rabbit liver DNA after immunization against this carcinogen.

The covalent binding of [3H]aflatoxin B1 (AF) to liver DNA was determined, 6 h after oral administration to male rabbits. A Covalent Binding Index, CBI (mumol AF/mol DNA-P)/(mmol AF/kg b.w.) = 8,500 was found. Pretreatment of rabbits with AF coupled to bovine serum albumin in Freund's adjuvant led to the production of AF-directed antibodies. Administration of [3H]AF to such immunized rabbits resulted in a CBI of only 2,500, i.e., the immunization provided a protection by a factor of more than 3. Although this is encouraging evidence for the potential of active immunization against genotoxic carcinogens, a number of points will have to be clarified, such as the time course for the DNA binding and the question of a possible shift to other target cells.